Addressing Maternal Mental Health to Increase Participation in Home Visiting

Background and Purpose: Maternal depression poses a significant threat to the healthy development of young children and is associated with increased child behavior problems and poorer cognitive development. Home visiting programs provide critical support for children and families during early childhood, but further research is needed to examine how programs address maternal depression and whether referral to outside mental health services impacts participation in home visiting. This study examined rates of depression among mothers in the national Parent as Teachers (PAT) home visiting program, whether family risk factors were associated with elevated depressive symptoms, and whether depressive symptomology and initiation of outside mental health treatment were associated with attendance and retention in services, particularly after considering important family risk factors.

Methods: Data from all participating PAT affiliates was collected nationally. Measures included family demographics and risk factors, rates of depression screening, maternal depressive symptoms, initiation of outside mental health services, and number of months enrolled in PAT. This subsample of 9,067 mothers included those screened with the Edinburgh Postnatal Depression Scale (EPDS), representing 225 PAT affiliates in 31 states. Mothers were 30.3 years of age on average (SD = 6.6), and the majority identified as White. Chi-square tests were conducted to explore whether meeting criteria for subclinical depression or probable Major Depressive Disorder (MDD) on the EPDS was associated with high-risk characteristics, and multiple regression was used to examine which risk factors were most strongly associated with depressive symptoms. Subsequently, linear mixed models were estimated to examine whether maternal depression status was associated with total number of months enrolled in PAT, and whether initiation of outside mental health services predicted PAT enrollment duration among mothers with depression. Mixed models included family demographic and risk variables and accounted for clustering by PAT site.

Results: Overall, 13.0% of mothers screened with the EPDS met criteria for probable MDD, and 10.2% met criteria for subclinical depression. Several high needs characteristics were strongly associated with maternal depressive symptoms, including parental intimate partner violence exposure (β= .13, p<.001), parental disability or health condition (β= .08, p<.001), and parental substance abuse (β= .07, p<.001). Mothers who screened in either the probable MDD or subclinical depression range were enrolled for fewer months in PAT (B = -1.64, p<.001 and B = -1.28, p<.05, respectively) than their nondepressed counterparts. However, depressed mothers who accessed outside mental health services stayed enrolled for more months than depressed mothers who did not access services (B = 3.49, p<.001).

Implications: Results demonstrate that mothers with higher depressive symptoms, including those in the subclinical range, have a harder time participating in home visiting services. However, when PAT home-visitors address maternal mental health and mothers initiate treatment, mothers participate in PAT for a longer period of time. Findings can inform national home visiting policies by promoting the use of lower cut-offs on depression screening tools to identify mothers at risk and encouraging the development of robust partnerships between home visiting and community mental health systems to support effective screening, referral, and initiation of services.